If you would like us to discuss your information with someone other than yourself, please fill out the Authorization for Disclosure of Protected Health Information form, which is available at QuartzBenefits.com/phiform. You can specify which information may be released to named people or entities. You may authorize anyone, including a friend, a family member, or an employer or potential employer. Once completed, you can return it to Quartz and an authorization will be entered to allow release of the requested information.

When may PHI be released without a member’s authorization?

To parents of a minor after verifying the parent’s identity and if permitted under the law

• HIPAA enforcement purposes
• When required by law (example: a court order requires it)
• Other uses/disclosures required or permitted by law
• For Quartz’s payment and healthcare operations purposes

Notice of Privacy Practices

Physicians Plus Insurance Corporation (PPIC) is now part of the Quartz Affiliated Covered Entity (ACE) with Unity, Gundersen Health Plan and Gundersen Health Plan Minnesota. Quartz ACE has a joint Notice of Privacy Practices. The Notice of Privacy Practices explains privacy practices, legal duties and members’ rights concerning their PHI.

You may access the Notice of Privacy Practices online at QuartzBenefits.com/privacy-practices or through MyChart.

If you prefer a printed copy, please call Quartz’s Privacy Official at (800) 362-3310 or email [email protected]. Members may also access information about their privacy online at QuartzBenefits.com/privacy-practices/data-usage-and-collection.